Nearly half of New York City's 4,400 emergency medical technicians and paramedics have tested positive for the COVID virus. Five have died, though that figure doesn't account for first responders who worked for private emergency response companies.
This article was published on Wednesday, February 24, 2021 in Kaiser Health News.
In his 17 years as an emergency medical provider, Anthony Almojera thought he had seen it all. "Shootings, stabbings, people on fire, you name it," he said. Then came COVID-19.
Before the pandemic, Almojera said it was normal to respond to one or two cardiac arrests calls a week; now he's grown used to several each shift. One day last spring, responders took more than 6,500 calls — more than any day in his department's history, including 9/11.
An emergency medical services lieutenant and union leader with the New York City Fire Department, Almojera said he has seen more death in the past year than in his previous decade of work. "We can't possibly process the traumas, because we're still in the trauma," he said.
EMS work has long been grueling and poorly paid. New FDNY hires make just over $35,000 a year, or $200 more than what is considered the poverty threshold for a four-person household in New York City. (That figure is on par with national averages.) Employee turnover is high: In fiscal year 2019, more than 13% of EMTs and paramedics left their jobs.
But COVID-19 has added a new layer of precarity to the work. According to Oren Barzilay, the Local 2507 union president, nearly half of its 4,400 emergency medical technicians and paramedics have tested positive for the COVID virus. Five have died, though that figure doesn't account for first responders who worked for private emergency response companies. Nationwide, at least 128 medical first responders have died of COVID, according to Lost on the Frontline, an investigation by KHN and The Guardian.
The problem of EMS pay was in the spotlight in December, when the New York Post outed paramedic Lauren Caitlyn Kwei for relying on an OnlyFans page to make extra money. Kwei, who works for a private ambulance company, wrote on Twitter: "My First Responder sisters and brothers are suffering … exhausted for months, reusing months old PPE, being refused hazard pay, and watching our fellow healthcare workers dying in front of our eyes." She added: "EMS are the lowest paid first responders in NYC which leads to 50+ hour weeks and sometimes three jobs."
Almojera earns $70,000 annually as a lieutenant, but his paramedic colleagues' salaries in non-leadership roles are capped at around $65,000 after five years on the job. He earns extra income as a paramedic at area racetracks and conducting defibrillator inspections. He has colleagues who drive for Uber, deliver for GrubHub and stock grocery shelves on the side. "There are certain jobs that deserve all your time and effort," Almojera said. "This should be your only job."
For Liana Espinal, a paramedic, union delegate and 13-year veteran of the FDNY, a sense of camaraderie and the opportunity to serve her fellow Brooklynites compensated for low pay and exhausting shifts. For years she was willing to take on overtime and even a second job with a private ambulance company to make ends meet.
But COVID changed that. The department switched from eight- to 12-hour shifts last summer, leaving Espinal, a single mother of three, too exhausted to pick up overtime. Like many healthcare workers, she isolated from her children at the outset of the pandemic to avoid potentially exposing them to the coronavirus, leaving them in the care of her own mother; she described being separated from her 1-year-old son as "devastating." Despite working round-the-clock to get the city through the early days of the pandemic, she often had to choose between paying rent on time or paying utility bills.
"After working this year, for me personally, it doesn't feel worth it anymore," she said. She is two exams shy of finishing a nursing degree she started studying for before the pandemic. She said the last year has only strengthened her resolve to shift careers.
The pandemic has disproportionately claimed Black and brown lives — Black and Hispanic people were significantly more likely than white people to die of COVID — and those disparities extend to healthcare workers. Lost on the Frontline has found that nearly two-thirds of healthcare workers who have died of COVID were non-white.
All five of the department's EMS employees who died of COVID were non-white.
They included Idris Bey, 60, a former Marine and 9/11 first responder who was known to stay cool under pressure. He was an avid reader who bought new books each time he got a paycheck.
Richard Seaberry, 63, was looking forward to retiring to the Atlanta area to be near his young granddaughter.
Evelyn Ford, 58, left behind four children when she died in December, just as the coronavirus vaccine became available to first responders in New York City. According to the City Council's finance division, 59% of EMS workers are minorities.
Almojera and Espinal see a racial component to pay disparities within the FDNY. Firefighters with five years on the job can make more than $100,000, including overtime and holiday pay, whereas paramedics and EMTs cap out at $65,000 and $50,000, respectively. According to the City Council finance division, 77% of New York firefighters are white.
"My counterpart fire lieutenants make almost $40,000 more than me," Almojera said. "I've delivered 15 babies. I've been covered head to toe in blood. I mean, what do you pay for that? You can at least pay us like the other 911 agencies."
A spokesperson for the FDNY declined to comment on pay.
The last year has also exacted an emotional toll on an already stressed workforce. Three of the FDNY's EMS workers died by suicide in 2020. John Mondello Jr, 23, a recent EMS academy graduate, died in April. Matthew Keene, 38, a nine-year veteran, died in June. Brandon Dorsa, 36, who had struggled with injuries from a 2015 workplace accident, died in July.
Family and colleagues told local news outlets that Mondello and Keene were struggling with trauma as a result of the pandemic. Last spring, New York Mayor Bill de Blasio and first lady Chirlane McCray announced a partnership between the U.S. Department of Defense and city agencies to help front-line health workers cope with the stress of working through the pandemic. But many EMS workers have said that the program has been difficult to access.
"There aren't a lot of resources for people, so a lot of EMS internalize what they go through," Almojera said. "It's not normal to see the things that we see."
Issues regarding pay and mental health challenges predate the pandemic: A national survey conducted in 2015 found EMS providers were much more likely than the general population to struggle with stress and contemplate suicide.
Almojera knew Keene and last spoke with him a week before his death. "You can't say enough nice things about the guy," he said. "I wish he had mentioned even a hint of [his struggles] on the phone. And I would have shared how I was feeling through all this."
He said he has felt a mix of pride, exhaustion and resignation over the past year. "I've seen the magic that you can do on the job," Almojera said. "And I've seen my brothers and sisters on this job cry after calls."
Almojera is now representing his union in talks with the city to renegotiate EMS and paramedic contracts. He said he hopes that city officials will think of the hardships he and his fellow first responders endured over the past year when they come to the negotiating table to discuss pay raises. But early talks have not been encouraging.
"After all the sacrifices made by our members," he said. "I don't know whether to be angry, flip the table, or just shrug my shoulders and give up."
This story is part of "Lost on the Frontline," an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of healthcare workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.
Women's health advocates are looking to Xavier Becerra to help swiftly unwind Trump-era funding cuts and rules that decimated the nation's network of reproductive health providers.
This article was published on Wednesday, February 24, 2021 in Kaiser Health News.
As President Joe Biden works to overhaul U.S. healthcare policy, few challenges loom larger for his health secretary than restoring access to family planning while parrying legal challenges to abortion proliferating across the country.
Physicians, clinics and women's health advocates are looking to Xavier Becerra, Biden's nominee to run the Department of Health and Human Services, to help swiftly unwind Trump-era funding cuts and rules that decimated the nation's network of reproductive health providers over the past four years.
But Becerra, who as California's attorney general fought the Trump administration's family planning restrictions, faces increasingly conservative federal courts that have backed efforts to restrict reproductive health services, including a Supreme Court dominated by Republican appointees.
The new administration must also contend with an energized anti-abortion movement looking to leverage political power in red state legislatures to finally achieve its decades-long quest to ban abortion outright.
Any Biden administration moves to preserve abortion and other family planning services could set up new legal battles between the federal government and states.
"It's a minefield," said Mary Ziegler, a law professor at Florida State University who has written extensively about the history of the nation's abortion debate.
"Expectations on both sides are extremely high," she said. "And the Supreme Court may force the issue to the top of the agenda if it does something aggressive to restrict abortion."
The outlines of the brewing showdown came further into focus Tuesday as Becerra faced opposition from a number of Republicans on the Senate health committee on the first of two days of confirmation hearings.
"For many of us, your record has been … very extreme," Sen. Mike Braun (R-Ind.) told Becerra at the hearing, accusing him of being "against pro-life." More than three dozen groups opposed to abortion rights have urged the Senate to reject Becerra, who has been a longtime advocate of abortion rights and federal support for contraceptives.
By contrast, Becerra has drawn strong support from abortion rights groups, which have applauded his efforts challenging Trump restrictions on family planning services. "He will be a great partner," said Alexis McGill Johnson, president of the Planned Parenthood Federation of America.
Becerra, whose wife, Dr. Carolina Reyes, is an obstetrician, is scheduled to appear before the Senate Finance Committee on Wednesday, after which his nomination is expected to move to the floor or the Senate for consideration by the whole body.
Successive presidential administrations since the 1980s have restricted or expanded federal support for family planning, depending on which party controlled the White House.
But tensions between the two sides intensified under President Donald Trump, making the task before Biden and Becerra that much more delicate.
Trump, who relied heavily on political backing from religious conservatives, moved more aggressively than his GOP predecessors to curtail access to abortion and clamp down on federal funding for clinics that provide reproductive care.
Organizations such as Planned Parenthood that long received federal money through the half-century-old Title X program were forced out of it when the Trump administration effectively barred recipients of federal aid from providing abortions or counseling women about the procedure.
That, in turn, led to widespread cutbacks at clinics across the country and huge drops in the number of people able to get family planning services, according to healthcare providers.
"We're seeing so many fewer clients," said Brenda Thomas, chief executive of Arizona Family Health Partnership, which coordinates the state's Title X program. Thomas said the number of patients in Arizona's program dropped 24% in 2019 after the Trump administration issued the new rules and declined an additional 40% in 2020, as the COVID-19 pandemic further hampered services.
In Missouri, a provider operating three family planning clinics left the program, leading to a 14% decrease in patients getting services through Title X, according to the Missouri Family Health Council.
And in California, the Title X restrictions led to a 40% reduction in patients in 2019, said Lisa Matsubara, general counsel at Planned Parenthood Affiliates of California.
Like many other family planning advocates, Matsubara said Biden needs to do more than just reverse the cuts. "We don't want to just, like, go back to what it was before the Trump administration," she said. "We're really looking and hoping that the administration really takes the necessary steps to expand access."
Biden has pledged to rewrite the family planning regulations so clinics providing reproductive health services can return to the program.
Within days of taking office, Biden issued an executive order to reverse other family planning restrictions imposed by the last administration, including rescinding the so-called global gag rule that prevented international aid groups that receive U.S. funding from counseling pregnant patients about abortion.
Rolling back some federal policies, like the restrictions on international aid, are relatively simple. Biden and Becerra likely also could quickly reverse Trump-era restrictions on mifepristone, a pill used to induce abortion early in a pregnancy.
But rewriting rules on funding for family planning or reissuing other complex regulations could be considerably more fraught, experts say.
"Both sides have really learned how to maximize use of courts," said Alina Salganicoff, who directs women's health policy at KFF, a health policy nonprofit. (KHN is an editorially independent program of KFF.)
"If anyone understands the legal challenges, it's Becerra," Salganicoff said. "But these are thorny issues. There are questions about how the Biden administration can move forward and how fast. And there's no question they are going to be sued."
After taking office, Biden said his administration would review the Title X restrictions, which are also under review by the Supreme Court.
As California attorney general, Becerra sued to stop the Trump administration rules. The case was rejected by lower federal courts, though a separate lawsuit in Maryland challenging the rules was successful, setting up the case for the Supreme Court.
Last month, the court issued its first abortion-related decision since Trump appointee Amy Coney Barrett replaced Ruth Bader Ginsburg, upholding a Trump-era rule that blocked mail delivery of mifepristone.
Many legal experts see more substantial court fights on the horizon as conservative-leaning states pass increasingly restrictive abortion laws.
Just last week, South Carolina Gov. Henry McMaster, a Republican, signed a bill barring abortions as soon as a fetal heartbeat can be detected with ultrasound, or about five or six weeks after a pregnancy begins.
The South Carolina law was temporarily blocked by a federal judge after Planned Parenthood filed a lawsuit.
The Supreme Court has never upheld a law as restrictive as South Carolina's. But the high court is the most conservative it has been in decades, raising the prospect that justices may reconsider the landmark 1973 Roe v. Wade decision, which recognized the right to an abortion.
That could force Biden — and potentially Becerra — to step much more directly into efforts in Congress to safeguard abortion rights, said Ziegler, the Florida law professor.
"There will be huge pressure on the Biden administration to do big, bold things," she said.
DeSantis has suggested that states that had instituted heavy restrictions on residents experienced severe repercussions for residents without reducing the number of COVID deaths.
This article was published on Wednesday, February 24, 2021 in Kaiser Health News.
The result of lockdowns "has been the destruction of millions of lives across America as well as increased deaths from suicide, substance abuse and despair without any corresponding benefit in COVID mortality."
For months, Florida Gov. Ron DeSantis has boasted about his state's "open for business" strategy in dealing with COVID-19 and how it's working better than so-called lockdown states.
Unlike in some other states, all Florida public schools are open for in-person learning, restaurants and bars have few restrictions, and the state has barred local governments from penalizing individuals for not wearing a mask in public.
In a recent rant against social network companies such as Facebook and Twitter, DeSantis suggested that states that had instituted heavy restrictions on residents experienced severe repercussions for residents without reducing the number of COVID deaths.
"Lockdowns at the time of the pandemic were favored by the, quote, 'narrative' and so, in the name of, quote, 'science,' articles and posts warning against lockdowns were taken down and censored," said DeSantis. "The result has been the destruction of millions of lives across America, as well as increased deaths from suicide, substance abuse and despair, without any corresponding benefit in COVID mortality."
We wondered whether that was true. Have state restrictions done such significant harm without providing any boost in the fight against COVID deaths? So we dug in.
Locking In on Lockdowns
To reduce the spread of the coronavirus, states have enacted — and then sometimes relaxed or lifted — various restrictions, including mask mandates, limits on restaurant capacity, stay-at-home orders and bans on large gatherings.
DeSantis, a Republican, has bristled at such statewide orders, even resisting pleas from local officials in Florida and criticizing other jurisdictions for implementing them. He has consistently questioned their effectiveness. Late last year, for instance, he claimed that states with lockdowns had COVID transmission rates twice as high as Florida's. We rated that Half True.
We asked DeSantis' office for any evidence supporting his more recent claim. The response reveals a mixed bag of information.
Check the Data: Did Florida's Path Lead to Less 'Despair'?
To support the governor's claim that other states have seen higher numbers of deaths from suicide, substance abuse and despair than Florida has during the pandemic, DeSantis' office sent information from the Centers for Disease Control and Prevention showing "all cause" mortality rates increased slower in Florida in 2020 — coinciding with the pandemic's first months through June 3 — over 2019 rates than in California and New York — two states that have opted for more regulations on public gatherings and mask-wearing. DeSantis' analysis showed Florida's rate rose 15% compared with 16% in California and 29% in New York.
But the "all causes" category goes far beyond deaths associated with suicide and drug abuse. It includes deaths from cancer, heart disease, lung disease and dementia, for example.
DeSantis' office did not provide any data showing how rates of suicide and drug abuse in Florida compared with those in so-called lockdown states. It sent us a Miami Herald article that said in Florida, according to preliminary medical examiners' statistics, 2,975 people died by suicide in 2020, down 13% from the previous year. But the article did not have nationwide data or figures from California or New York.
Concerning overdose deaths, DeSantis' office did not provide specific information. However, health experts said the pandemic likely did increase opioid overdoses. But the latest, provisional CDC data on drug overdose deaths shows Florida's numbers rising faster than the national average.
Comparing the 12-month period ending in June 2020 to the prior 12 months, the period for which data is available, Florida had a 34% increase in the rate of overdose deaths compared with a 20% national average among states. California had a 23% increase and New York had an 18% increase.
Meanwhile, federal suicide data reflecting the months in which the pandemic has transpired will not likely be available until 2022. Experts say that anecdotal evidence suggests a possible uptick in suicide rates during the pandemic. In addition, an online tool offered by the nonprofit Mental Health America to help screen for mental health issues showed a slight increase last year in people having suicidal thoughts.
Nonetheless, Paul Gionfriddo, the group's CEO, said he knows of no studies showing that so-called lockdown states have higher rates of suicide than those with fewer restrictions.
Gionfriddo said DeSantis may think he is mitigating the harmful effects of loneliness by not limiting public gatherings. But loneliness is not the only reason people cite in considering suicide, he said. Grief, financial insecurity and other factors also play a role, he said.
John Auerbach, president and CEO of Trust for America's Health, a nonprofit think tank, said it's difficult to pinpoint the psychological impact of restrictions to reduce infection because rules vary by state and within states, and such regulations have been imposed and lifted at different times.
Auerbach said he knows of no evidence that links states' COVID restrictions to suicides or drug overdose deaths.
"There are many contributing factors to suicide and drug overdoses," he said. The pandemic itself is having the biggest effect on heightening people's risk of dying from suicide and drug abuse — not the states' different approaches to prevent the transmission of infection, he added.
"It is the underlying pandemic that is at the root of increased risks," Auerbach said.
Factoring In COVID Mortality Rates
DeSantis also argued that statewide restrictions did not bring any corresponding benefit in limiting COVID mortality.
We asked his office for evidence. They again pointed to the CDC increase in "all cause" mortality data that showed California's rate was slightly higher than Florida's. But those statistics cover all causes of death, and people are still dying of diseases and conditions besides COVID.
We then consulted three epidemiologists to get their take. They all said the governor was playing loose with the facts. They stressed varying factors that affect states' mortality rates — from the weather to socioeconomic indicators to access to health services.
The epidemiologists pointed to the latest CDC data, which indicated that Florida's COVID mortality rate is higher than California's and seemed to undercut DeSantis' position that lockdowns have only hurt states.
As of Feb. 22, Florida ranked 28th in COVID death rates while California ranked 33rd, according to the latest CDC data, as compiled by Statista.
"That would bolster the argument that restrictions are one factor involved in lowering death rates," said Nicole Gatto, an associate professor of public health at Claremont Graduate University in California.
Numerous others also have an effect, Gatto said, so it is impossible to compare states using current data based on their strategies.
"I do think it is an oversimplification to make the assertion that the governor did without further study of the numerous variables involved, characteristics of the population, timing of interventions and the limitations of the data," she said.
Our Ruling
DeSantis said lockdown states have seen "increased deaths from suicide, substance abuse and despair without any corresponding benefit in COVID mortality."
The pandemic certainly has caused anxiety and distress across the country, and state and local restrictions designed to tamp down on the coronavirus's spread have also affected people's financial and emotional well-being. But currently, no clear data supports DeSantis' strongly worded claim. Researchers agreed that more research is necessary before such broad conclusions could be drawn. In addition, experts said that COVID death rates vary by state and numerous factors beyond state strategies to combat the virus affect this metric.
Email correspondence with Meredith Beatrice, DeSantis spokesperson, Feb. 10 and 11, 2021
Telephone interview with John Auerbach, president and CEO of Trust for America's Health, Feb. 12, 2021
Email interview with Nicole Gatto, MPH, Ph.D., associate professor of public health at Claremont Graduate University, Feb. 18, 2021
Email interview with William Miller, professor of epidemiology at the Ohio State University, Feb. 18, 2021
Telephone interview with Dr. Robert Murphy, professor of medicine and biomedical engineering and executive director, Northwestern University's Institute for Global Health, Feb. 18, 2021
Statista, Death rates from coronavirus (COVID-19) in the United States as of Feb. 17, 2021, by state, accessed Feb. 22, 2021
Miami Herald, "One Pandemic Positive: Suicides in Florida Actually Plummeted. Experts Worry It Won't Last," Feb. 10, 2021
PolitiFact, "Is Florida Doing Better on COVID-19 than 'Locked Down' States? Dec. 2, 2020
The Rev. Jose Luis Garayoa survived typhoid fever, malaria, a kidnapping and the Ebola crisis as a missionary in Sierra Leone, only to die of covid-19 after tending to the people of his Texas church who were sick from the virus and the grieving family members of those who died.
Garayoa, 68, who served at El Paso’s Little Flower Catholic Church, was one of three priests living in the local home of the Roman Catholic Order of the Augustinian Recollects who contracted the disease. Garayoa died two days before Thanksgiving.
Garayoa was aware of the dangers of covid, but he could not refuse a congregant who sought comfort and prayers when that person or a loved one fought the disease, according to retired hairstylist Maria Luisa Placencia, one of the priest’s parishioners.
“He could not see someone suffering or worried about a child or a parent and not want to pray with them and show compassion,” Placencia said.
Garayoa’s death underscores the personal risks taken by spiritual leaders who comfort the sick and their families, give last rites or conduct funerals for people who have died of covid. Many also face challenges in leading congregations that are divided over the seriousness of the pandemic.
Ministering to the ill or dying is a major role of spiritual leaders in all religions. Susan Dunlap, a divinity professor at Duke University, said covid creates an even greater feeling of obligation for clergy, because many patients are isolated from family members, she said.
People near death often want to interact with God or make things right, Dunlap said, and a clergy member “can help facilitate that.”
Such spiritual work is key to the work of hospital chaplains, but it can expose them to virus being spread in the air or sometimes through touch. Jayne Barnes, a chaplain at the Billings Clinic in Montana, said she tries to avoid physical contact with covid patients, but it can be difficult to resist a brief touch, which is often the best way to convey compassion.
“It’s almost an awkward moment when you see a patient in distress, but you know you shouldn’t hold their hand or give them a hug,” Barnes said. “But that doesn’t mean that we can’t be there for them. These are people who cannot have visitors, and they have a lot they want to say. Sometimes they are angry with God, and they let me know about that. I’m there to listen.”
Still, there are times, Barnes said, that the despair is so profound she cannot help but “put on a glove and hold a patient’s hand.”
Barnes was diagnosed with covid near Thanksgiving. She has recovered and has a “better understanding” of what patients are enduring.
Dealing with so much suffering affects even the most hardened doctors and nurses, she said. Billings Clinic staffers were devastated when a beloved physician died of covid, and rallied behind a popular nurse who was seriously ill but recovered.
“We’re not only taking care of the patients; we are also there for the staff, and I think we have been an important asset,’’ she said of the hospital’s chaplains.
In Abington, Pennsylvania, Pastor Marshall Mitchell of Salem Baptist Church said he believes part of his spiritual duty is to persuade his congregation and the broader African American community to take precautions to avoid covid. That is why Mitchell allowed photographers to capture the moment in December when he received his first dose of a vaccine.
“As pastor of one of the largest churches in the Philadelphia region, it is incumbent on me to demonstrate the powers of both science and faith,” he said.
Mitchell said he might have credibility in convincing other African Americans, who have been disproportionately affected by covid, that a vaccine can save lives. Many are skeptical.
The politicization of covid precautions such as masks and social distancing has put many pastors in a difficult position.
Mitchell said he has no patience for people who refuse to wear masks.
“I keep them the hell away from me,” he said.
Jeff Wheeler, lead pastor of Central Church in Sioux Falls, South Dakota, said that his church encourages mask-wearing and that most congregants comply. However, the underlying tension is reflected in his message to members on the church’s website:
“As we move forward, we simply ask you to avoid shaming, judging or making critical comments to those wearing or not wearing masks,” it reads.
Sheikh Tarik Ata, who leads the Orange County Islamic Foundation in California, said that the Quran calls for Muslims to take actions to ensure their health and that congregants largely comply with covid guidelines
“So, our members don’t have a problem with mask mandates,” he said.
Covid has hit the Orange County Muslim population hard, Ata said. Religion has become an important source of comfort for members who have lost their jobs and struggled with illness or finding child care.
“Our faith says that no matter how difficult the situation, we always have access to God and the future will be better,” Ata said.
Adam Morris, the rabbi at Temple Micah in Denver, said he has turned to online video to meet with congregants sick with the coronavirus. When meeting with his congregation members in person, such as during graveside services, he worries that with his mask on people might miss seeing the concern and compassion he feels for their plight.
He conducts in-person graveside funerals for a small number of mourners but requires all participants to wear masks.
Observant Muslims and Jews believe it is important to bury the dead quickly after death, Morris said.
“Some traditions and rituals must go forward,” Morris said, “covid or not.”
As an increasing number of vaccine vials are shipped in coming weeks, the concern about shortages may well shift to human capital: the vaccinators themselves.
This article was published on Tuesday, February 23, 2021 in Kaiser Health News.
Beating back COVID right now comes down to balancing supply and demand.
With hopes pinned to vaccines, demand has far outstripped the supply of doses.
But, as an increasing number of vaccine vials are shipped in coming weeks, the concern about shortages may well shift to human capital: the vaccinators themselves.
"We need to mobilize more medical units to get more shots in people's arms," Jeff Zients, coordinator of President Joe Biden's COVID-19 task force, said at a briefing earlier this month.
Already, there have been scattered reports that vaccinators are in short supply in some areas.
"Absolutely, we do need more," said Tom Kraus, vice president of government relations for the American Society of Health-System Pharmacists, whose members work in hospitals, clinics and large physician practices.
After all, vaccinating America is a huge undertaking.
"We are planning to vaccinate a lot more people over a shorter period of time than we've ever done before," said L.J Tan, chief strategy officer of the Immunization Action Coalition, which distributes educational materials for healthcare professionals and the public across a range of vaccination topics.
Each year the U.S. vaccinates 140 million to 150 million residents against influenza, "but what we're talking about now is much more intensive," he said. For COVID, the goal is to get vaccines out quickly to all those eligible in a country of 330 million people.
A state-by-state survey would be required to estimate how many total vaccinators are needed nationally, Tan said.
Still, experts are cautiously optimistic that this won't be a hard problem to fix, pointing to efforts underway to recruit current and retired medical professionals, as well as medical students and nurses in training.
"As long as we continue to see this interest in volunteering, we should have a sufficient workforce to do it," said Deb Trautman, president and CEO of the American Association of Colleges of Nursing.
Not just anyone can be a vaccinator. One can't merely walk into a center and offer to help give shots. The training requirements vary by state.
To boost the effort, both the Trump and Biden administrations, using an emergency preparedness law first adopted in 2005, expanded liability protections.
With the recent expansions, those qualifying include pharmacy interns and recently retired doctors and nurses, as well as physicians, nurses and pharmacists. The government estimates there are about half a million inactive physicians and 350,000 inactive registered nurses and practical nurses in the United States.
States are also greenlighting dentists, paramedics and other first responders, said Kim Martin, director of immunization policy at the Association of State and Territorial Health Officials.
Some are also turning to nursing and medical schools, where faculty and students are often eager to participate. More than 300 schools nationally have signed a pledge offering to help administer the vaccine, according to the American Association of Colleges of Nursing.
The University of Houston College of Nursing, for example, altered its curriculum specifically to prepare students for administering COVID vaccines — and teams of students and faculty have helped at community vaccination sites.
Others are joining the effort.
The Medical Reserve Corps, a national network of volunteer groups, has more than 200 units in about 40 states, Puerto Rico, American Samoa and the Northern Mariana Islands assisting with various vaccination efforts, including administering the shots, according to a Health and Human Services spokesperson.
And the military is pitching in, too, with the Pentagon approving the use of more than 1,000 active-duty service members to help the Federal Emergency Management Agency with mass vaccinations sites, the first one set for California.
Although some of these groups give ballpark figures of volunteers, it's hard to tally just how many have stepped forward in recent months to help vaccinate.
Becoming a Vaccinator
"It should not be left to just anyone that is willing, as there are clinical skills and preparedness that is required," said Katie Boston-Leary, director of nursing programs at the American Nurses Association.
Even those skilled in giving shots may need a training booster in the war against COVID.
When she volunteered, Boston-Leary said, she was required to complete four to six hours of online training across a wide range of topics, from the optimal way to administer intramuscular injections, to specific information about the two vaccines now on the market.
"Even a nurse like me has to go through that training," said Boston-Leary.
To aid states in setting up training, the Centers for Disease Control and Prevention offered recommendations that all healthcare staff members receive training in COVID vaccination "even if they are already administering routinely recommended vaccines."
The CDC has different training modules, based on experience level. For instance, there's a module for those who have given vaccinations in the previous year, but a different one for those who haven't done so for more than a year. The time required to complete programs varies — people with the most recent experience require less total training time.
Tan said training laypeople with no medical background to give vaccines "is not the way to go."
Instead, such volunteers can be used to help with logistics, such as directing people to the right areas, managing traffic, moving supplies around and similar duties.
Training programs exist even for people who aren't vaccinators but assist with storing, handling or transporting the vaccines. That's important because the two vaccines currently in use — one from Pfizer-BioNTech and one from Moderna — have different storage requirements.
They are shipped in multidose vials, which is not unusual for vaccines. The vaccinators themselves often draw up the syringes out of the vials, said Tan.
To avoid slowdowns as patients move through the lines, some vaccination centers have other trained staffers pre-fill individual syringes. Anyone doing this task should be "someone trained in administering vaccines as well," said Tan.
At the clinic where Katie Croft-Walsh, 65, volunteered recently in San Antonio, her only job was to administer the vaccine. Other volunteers took care of registering patients, pre-filling the individual syringes and other logistical efforts.
She decided to volunteer after hearing that help was needed. The move came with a bonus: She would get the vaccine herself at the end of her first day participating, something she already qualified for based on her age but had been unable to secure.
A practicing lawyer, Croft-Walsh previously worked as a registered nurse and kept her license current by taking required courses each year since leaving her hospital job in 1998.
Training occurred on her first day at the mass vaccination site and covered details about each type of vaccine, along with the types of syringes available, the right place to inject the dose and other information. Her group, which she said included nurses, dentists, pharmacists and upper-level nursing students, were trained and overseen by health department physicians.
The patients were all thrilled to get a dose.
"Everyone was very kind and nice," even if they had to wait a bit in line, she said.
She liked the experience so much that she has volunteered at more clinics — and plans to start volunteering with fire departments as they begin community clinics in her city.
"It made me remember why I went into nursing in the first place," said Croft-Walsh.
Remember, No Squeezing!
To ensure safety, training is important, Martin of the state health officers group said. It's not that hard to give an intramuscular injection, but you need to place it in the right spot. For adults, that area is in the deltoid muscle, "not too far up the shoulder, not too far down," she said, both to avoid injury and to make sure the vaccine goes into the muscle.
Training videos show vaccinators how to find the ideal location, first locating the bony point in the shoulder, then measuring two or three finger widths down and placing the needle in the middle of the arm.
Administering an intramuscular vaccine too high on the shoulder can cause a rare and painful injury. Such injuries were more common years ago when influenza vaccines were first rolling out, said Tan of the immunization coalition. Training on proper technique helped reduce cases since then, he said, and is also part of current efforts to train vaccinators.
It's also important not to pinch patients' arms when administering the vaccine, said Tan, responding to a question about a hashtag making the rounds on Twitter called #DoNotSqueezeMyArm.
For intramuscular injections to be most effective, the needle needs to penetrate the muscle, not fat.
"When you squeeze the arm, it pushes up the fat layers," said Tan.
Those getting the vaccines, he said, can play a role, too.
"I encourage patients to ask questions," said Tan. "If they're concerned their arm is being squeezed, speak up. Not in a hostile manner, but say something like, 'Hey, I read this thing about not squeezing arms. Can you explain why you're squeezing mine?'"
The U.S. government has invested billions of dollars in manufacturing, used a wartime act dozens of times to boost supplies and yet there's still not enough COVID vaccine on the way to meet demand — or even the government's own goals for national immunization.
President Joe Biden, in remarks at the National Institutes of Health this month, said the nation is "now on track to have enough supply for 300 million Americans by the end of July." But at the current rate of production, Pfizer and Moderna will miss their targets of providing at least 100 million doses each by the end of March, let alone 200 million more doses each has promised by July.
Moderna would need to more than double its vaccine production rate from January — when it made roughly 19 million doses — to meet its contractual obligations. Pfizer supplied 40 million vaccine doses by Feb. 17. It has roughly six weeks left to deliver the first 120 million doses it has promised.
Biden and officials from the two companies say they are rapidly expanding production capacity. But critics are lining up. They want to know whether the government did enough, fast enough, to guarantee that companies would meet the urgent challenges of the pandemic. As for the manufacturers bolstered by extraordinary sums of taxpayer money, why did they not share technology and know-how sooner, or move more quickly into strategic production partnerships?
Experts say it's complicated, noting that the output of raw materials and assembly lines can't be ratcheted up 10,000-fold at the push of a button — and that the effort thus far has been close to miraculous. They cite bottlenecks in at least three areas: the production of specialty lipids, fatty materials that are a primary component of the Moderna and Pfizer-BioNTech vaccines; the hundreds of millions of glass vials that hold the vaccine; and the sterile automated assembly lines where vaccine moves from bulk containers into vials before shipment.
U.S. officials have run headlong into the limits of the Defense Production Act, a Korean War-era law that allows the federal government to ramp up supplies of critical materials in times of national emergency. The vaccine manufacturing process relies on a complex supply chain, from sourcing raw materials and equipment to designing chemical processes, building production lines and hiring and training workers.
Also, experts note, no one knew which vaccines would prove effective.
"A year ago there was no commercial market for mRNA product. There was scientific research and pharma making small-volume clinical lots. Now we need billions of doses, in the space of a year. That's overloading the supply infrastructure," said Kevin Gilligan, a senior consultant with Biologics Consulting and a former official with the Biomedical Advanced Research and Development Authority, or BARDA, a federal agency created in 2006 to deal with pandemics and bioterrorism.
As of December, the Trump administration through its Operation Warp Speed initiative had obligated nearly $14 billion for vaccine development and manufacturing, including investments to expand U.S. capacity, according to a Government Accountability Office report in January. The administration invoked the Defense Production Act on at least 23 vaccine-related contracts, in part to prioritize the government's contracts over others, according to a KHN review of the federal contracts database, contracts obtained by the nonprofit group Knowledge Ecology International, GAO and government news releases.
They include the December contract that the Department of Health and Human Services signed with Pfizer for another 100 million doses, on top of the initial 100 million it committed to last summer. That contract, worth $1.95 billion, included DPA provisions to give the company priority access to raw materials and spare parts for factories, according to a former administration official.
The DPA has also been used in vaccine contracts with Moderna, Johnson & Johnson and other drug companies for hundreds of millions of doses. On top of that, the law has been invoked for at least 10 contracts with companies making needles or syringes. It's been used to require glass makers Corning and SiO2 Materials Science to prioritize vial production for vaccine production, and in contracts for aspects of manufacturing with companies like Emergent BioSolutions, Fujifilm Diosynth Biotechnologies and Grand River Aseptic Manufacturing.
Operation Warp Speed awarded Emergent BioSolutions $648 million last year to boost the manufacturing capacity it needed to enter agreements with Johnson & Johnson and AstraZeneca — worth at least $615 million and $261 million, respectively — to help make their vaccines. Grand River Aseptic Manufacturing won a $160 million award from BARDA and has contracted with Johnson & Johnson to fill vials and finish packaging of its single-shot COVID vaccine, which is expected to get emergency authorization from the Food and Drug Administration as soon as this month but will only have a few million doses available initially.
The Biden administration has expanded its use of the wartime act to prioritize equipment like filling pumps and filtration systems for Pfizer. "We told you that when we heard of a bottleneck on needed equipment, supplies or technology related to vaccine supply, that we would step in and help," Tim Manning, the White House official leading the administration's COVID supply efforts, said during a February press briefing.
Yet it can do only so much, according to medical supply chain experts. Prashant Yadav, a senior fellow at the Center for Global Development at Harvard University, said it could take months for the impact of that DPA action to be felt because of the time it takes to procure equipment and get it installed, with each step tightly regulated.
The U.S. is unlikely to get a meaningful bump in capacity "unless we think about co-production deals," in which a drug company agrees to manufacture a competitor's vaccine, said Tinglong Dai, an associate professor at Johns Hopkins University's Carey Business School.
So far, such arrangements have proliferated in Europe — which has less capacity to produce drugs than the United States does. Deals with other major vaccine manufacturers have been less common on the U.S. side of the pond.
"Though we have not partnered with, say, another large pharma for production, we have built strategic partnerships with a number of organizations that have been instrumental to our scaling up and meeting supply and commercialization plans," Moderna spokesperson Ray Jordan said in an email.
Moderna this month said that its manufacturing process would scale up rapidly in the coming weeks, that it would provide the U.S. between 30 million and 35 million doses in February and March and between 40 million and 50 million doses monthly from April to July. The company declined to elaborate on what made the boost possible.
Vaccine manufacturers long ago should have been sharing technology and expertise to boost production in the U.S. and Europe, and especially in developing countries, said James Love, director of Knowledge Ecology International, a nonprofit focused on patent rights.
"We've wasted about a year by not doing some of the obvious things," he said. "The rhetoric is that it's an emergency. But on the scale-up of manufacturing, you just don't see it."
It's not that simple, others say. "There wasn't any excess capacity available in the United States a year ago. Zero," Paul Mango, a former HHS official heavily involved in Operation Warp Speed, said regarding vaccines. "It's getting the equipment. It's quality control. It's getting the employees. People make it sound like this is easy. You can't just push 400 workers and say, go at it."
Each Pfizer-BioNTech or Moderna shot contains billions of lipid nanoparticles, each particle containing four lipids and a strand of the nucleic acid RNA, the five pieces assembled in a way that allows the RNA to enter our cells and create a particle that stimulates the immune system to defend against the COVID virus.
The lipids, which are made only in a handful of factories, have been a major supply problem. "No one has ever thought of a scenario where we would use lipid nanoparticle formulation for [billions of] doses," Yadav said. "We have not invented a process for doing lipid nanoparticles at scale."
Two of the lipids in the vaccine, cholesterol and DSCP, have long been used in industry to shape and buffer chemical formulations. A third lipid prevents the particles from clumping together. A fourth enables the lipid shell of the vaccine to fuse with human cells and, once inside the cell, to crack open so the RNA can move to a structure called a ribosome and make proteins that stimulate immunity.
All of these raw materials are produced under regulated conditions — in Massachusetts, Missouri, Colorado and Alabama by companies under license with Moderna, Pfizer or Acuitas Therapeutics, which was co-founded by Pieter Cullis, a University of British Columbia professor who is considered the grandfather of lipid nanoparticle technology.
Before the pandemic, these companies produced meager amounts for use in small clinical trials, laboratory experiments or in one licensed drug, patisiran, which is used to treat a rare genetic disease in about a thousand people worldwide. Now they are producing thousands of kilograms of the stuff, said Stefan Randl, a vice president at Evonik, a lipid maker. Evonik recently announced it would scale up production at two German sites, possibly in the second half of the year, to be used in the Pfizer-BioNTech vaccine. The company last year bought a U.S. lipid manufacturer in Alabama.
"All of a sudden the quantities had to be ramped up a thousand-fold or more," Randl said. "This is the biggest bottleneck."
Several elements of the vaccine, including lipids and enzymes used in making the mRNA, until recently were produced using animal products such as sheep's wool, said Andrew Geall, chief scientific officer at Precision NanoSystems, which designs equipment for mixing the mRNA and lipids. Animal products could cause contamination or disease, even in minute quantities, so manufacturers now use synthetic chemicals.
Luckily, the cosmetic industry — a major user of some of the same lipids used in the vaccines — has been switching from animal products in recent decades, noted Julia Born, an Evonik spokesperson.
Still, only a limited number of companies globally have expertise and facilities to make the lipids, said Thomas Madden, CEO and a co-founder of Acuitas, and they've all struggled to move from quantities produced in a laboratory to industrial-scale production. For instance, he said, hazardous solvents and chemicals used in laboratory procedures need to be avoided in industrial processes, where they could give rise to workplace safety issues.
"This is a hugely complex supply chain," Madden said. "Once you address a bottleneck at one point, you identify the next bottleneck in the process. It's a bit of a game of whack-a-mole."
Although it's not particularly difficult to make the lipids used in vaccines, it takes time to get FDA authorization of a facility that can make them in high quantities, said Cullis, the UBC professor. It would take two to three years to start such a factory from scratch, so instead, Moderna and Pfizer-BioNTech have been hooking up with existing manufacturers and getting them to convert to lipid production, he said.
Another bottleneck is "fill/finish" — getting the finished vaccine into vials or syringes so the shots can be shipped to customers. Vaccine filling lines require extremely high levels of efficiency and sterility, and few companies in the world have this capacity, said Mike Watson, former president of Valera, a Moderna subsidiary. Moderna has hired Catalent, a contract manufacturer that recently experienced delays that slowed the release of some doses, to fill and finish U.S. doses at its facility in Bloomington, Indiana. At least two other companies will do the same for Moderna's vaccine supply abroad.
In January, the French multinational Sanofi — whose own COVID vaccine has been delayed by poor performance in producing immunity — agreed to offer its fill/finish line in Germany for the Pfizer-BioNTech vaccine. That line isn't expected to be running until July.
In the U.S., the number of vaccine doses shipped to states has ticked up in recent weeks, partly because Pfizer said its five-dose vials actually provide six shots. Moderna is seeking FDA permission to add up to five doses to its 10-dose vials.
Pfizer has said it is manufacturing raw materials in St. Louis, the active ingredients for the vaccine in Andover, Massachusetts, and filling vials in Kalamazoo, Michigan.
CEO Albert Bourla, with Biden at his side in Kalamazoo on Friday, said the company added lipid production capabilities at plants in Michigan and Connecticut, as well as fill/finish lines in Kansas. He said it has significantly cut the average time it takes to make doses — from 110 days to 60 days.
"Today, during this meeting, the president challenged us to identify additional ways in which his administration could help us potentially accelerate even further the delivery of the full 300 million doses earlier than July," Bourla said. "The challenge is accepted, and we will try to do our best."
The science says "open the schools, stop wearing masks outside, and everyone at low risk should start living normal lives." — Blog post by conservative talk show host Buck Sexton posted on Facebook, Feb. 8.
This article was published on Tuesday, February 23, 2021 in Kaiser Health News.
A popular Facebook and blog post by conservative radio host Buck Sexton claims scientific research indicates life should return to normal now despite the persistence of the covid-19 pandemic.
“Here’s what the science tells anyone who is being honest about it: open the schools, stop wearing masks outside, and everyone at low risk should start living normal lives. Not next fall, or next year — now,” reads the blog post, posted to Facebook on Feb. 8.
The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about PolitiFact’s partnership with Facebook.)
KHN-PolitiFact messaged Sexton via his Facebook page to ask if he could provide evidence to back up the statement but got no response.
So we reviewed the scientific evidence and talked to public health experts about Sexton’s post. Overall, they disagreed, noting the ways in which it runs counter to current public health strategies.
Let’s take it point by point.
'Opening the Schools'
In March, when government and public health leaders realized the novel coronavirus was spreading throughout the U.S., many public institutions — including schools — were ordered to shut down to prevent further spread. Many students finished the 2020 spring semester remotely. Some jurisdictions did choose to reopen schools in fall 2020 and spring 2021, though others have remained remote.
Throughout the pandemic, researchers have studied whether in-person learning at schools contributes significantly to the spread of covid. The findings have shown that if K-12 schools adhere to mitigation measures — masking, physical distancing and frequent hand-washing — are adhered to, then there is a relatively low risk of transmission.
And getting kids back into the classroom is a high priority for the Biden administration.
n a Feb. 3 White House press briefing, Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention, said data suggests “schools can safely reopen.” The CDC on Feb. 12 released guidance on how schools should approach reopening. It recommends the standard risk-mitigation measures, as well as universal masking, contact tracing, creating student learning cohorts or pods, conducting testing and monitoring community transmission of the virus.
Susan Hassig, associate professor of epidemiology at Tulane University, said science shows that schools can open safely if “mitigation measures are implemented and maintained in the school space.”
Here’s some of the latest research that tracks with these positions:
Only seven covid cases out of 191 were traced to in-school spread in 17 rural K-12 Wisconsin schools that had high mask-wearing compliance and were monitored over the 2020 fall semester.
Mississippi researchers found most covid cases in children and teenagers were associated with gatherings outside of households and a lack of consistent mask use in schools, but not associated with merely attending school or child care.
Thirty-two cases were associated with attending school out of 100,000 students and staff members in 11 North Carolina schools, where students were required to wear masks, practice physical distancing and wash hands frequently.
Of course, there are some limitations to these studies, which often rely on contact tracing, a process that can’t always pinpoint where cases originate. Some of the studies also rely on self-reporting of mask-wearing by individuals, which could be inaccurate.
Additionally, Hassig pointed out that not all school districts have the resources, such as physical space, personnel or high-quality masks, to open safely.
Sexton’s assertion that schools can reopen leaves out a key piece of information: that safe reopening is highly dependent upon use of mitigation measures that have been shown to tamp down on virus spread.
'Stop Wearing Masks Outside'
Because the coronavirus that causes covid is relatively new, the research on outdoor mask use is limited. But so far science has shown that masks prevent virus transmission.
The CDC study published Feb. 10 reported that a medical procedure mask (commonly known as a surgical mask) blocked 56.1% of simulated cough particles. A cloth mask blocked 51.4% of cough particles. And the effectiveness went up to 85.4% if a cloth mask was worn over a surgical mask.
Another experiment from the study showed that a person in a mask emits fewer aerosol particles that can be passed on to an unmasked person. And if both are masked, then aerosol exposure to both is reduced by more than 95%. A multitude of reports also show more generally that mask-wearing is effective at reducing the risk of spreading or catching other respiratory diseases.
Sexton’s post, however, advised that people should stop wearing masks outside. To be sure, public health experts agree the risk of transmitting covid is lower outdoors than indoors. But the experts also said that doesn’t mean people should stop wearing masks.
“The wind might help you a bit outside, but you are still at risk of breathing in this virus from people around you,” said Dr. Rachel Vreeman, director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai.
Being outside is “not a guarantee of safety,” reiterated Stephen Morse, an epidemiology professor at Columbia University Medical Center. “Especially when those people without masks are close together.”
The CDC addressed the issue of whether masks are needed outside in the agency’s mask guidelines: “Masks may not be necessary when you are outside by yourself away from others, or with other people who live in your household. However, some areas may have mask mandates while out in public, so please check for the rules in your local area.”
Overall, the prevailing scientific opinion is that, while it may be OK to go maskless outside if you are physically distant from others, mask-wearing is still recommended if you are around others.
'Everyone at Low Risk Should Start Living Normal Lives'
All the public health experts we consulted agreed this part of the claim is absolutely false. It flies in the face of what scientists recommend should be done to get through the pandemic.
While it’s unclear what exactly the post means by “low-risk” people, let’s assume it’s referring to younger people or those without health conditions that make them more vulnerable to covid. And that “living normal lives” refers to no longer wearing masks, physical distancing or washing hands with increased frequency.
News reports and scientific evidence show that bars, parties and other large gatherings can quickly become spreader events. Moreover, even young people and those without preexisting health conditions have gotten severely ill with covid or died of it.
Even if a low-risk person doesn’t get severely sick, they could still infect others in higher-risk groups.
The sentiment of this post is similar to calls early in the pandemic to let life return to normal in an attempt to achieve herd immunity. But, on the way to achieving that goal, many would die, said Josh Michaud, associate director for global health policy at KFF.
“Everyone going back to ‘normal’ right now, especially in the presence of more transmissible and more deadly variants, would be a recipe for further public health disasters on top of what we’ve already experienced,” he added.
The push to “return to normal” is precisely what let the new variants form and multiply, said Vreeman. “If we can ramp up getting people vaccinated and keep wearing masks in the meantime, only then will we have a chance at getting back to ‘normal.’”
Indeed, because of the new variants circulating in the U.S., Walensky and Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, have urged Americans not to relax their efforts to control the virus’s spread.
Our Ruling
A blog post by conservative talk show host Buck Sexton claims scientific evidence shows that right now we should “open the schools, stop wearing masks outside, and everyone at low risk should start living normal lives.”
Scientific research shows that in order for schools to reopen safely, risk mitigation measures must be put in place, such as requiring masks, rigorous hand-washing and limiting the number of students in classrooms. These changes, though, would not represent a return to normal, but a new normal for students and teachers.
The remainder of Sexton’s statement strays further from current science. Research indicates that you’re safer outdoors than indoors, but public health experts still recommend wearing masks in public, even outside. Science does not support the idea that the time is right for some people to resume life as normal. That would allow the virus to continue to spread and have a large human cost in hospitalizations and deaths, said the experts.
Posting about their day is a regular practice for Generations Y and Z, especially when they have something novel or exclusive to share. So, in the thick of a global pandemic, and with the shaky rollout of COVID vaccines making them somewhat of a holy grail, it's no surprise selfies featuring the coveted shot are infecting social media timelines.
It might engender envy, even outrage, especially if the person posting seems to have cut the line. But what if the intention was to encourage others to also get the shot? Does that make it OK?
Since the pandemic began, people around the world are increasingly living out significant portions of their lives online. But with 72% of the American public using some type of social media, according to the Pew Research Center, who sets the rules for proper social media etiquette?
"This is a totally new type of world to have a pandemic in," said Catherine Newman, the etiquette columnist at Real Simple and author of the book "How to Be a Person." One advantage of using social media, she said, is that people can create waves of public opinion from which everyone can benefit. Newman, who also volunteers at a hospice, was vaccinated and posted a selfie. She said the selfies can help address some of the public health mistrust issues that have contributed to vaccine hesitancy.
"I don't want to see a picture of your yacht on social media," she said. She'd rather see COVID vaccine selfies but cautions users to be mindful of the caption they choose.
After all, nearly 500,000 American lives have been lost in the pandemic and stark disparities have emerged in vaccination rates — especially among communities of color and older adults who are in the highest risk categories.
It raises the question: Is posting a vaccine selfie on your social media account a faux pas or still par for the course?
Elaine Swann, a lifestyle and etiquette expert, a certified mediator in the state of California and the founder of the Swann School of Protocol in Carlsbad, California, echoed those precautions. "RNs and front-line workers have a very different story to tell than a 20-something-year-old who got vaccinated for some obscure reason," she said.
At the same time, she said, it's not necessarily clear how someone came to be eligible for the vaccine. A person could present young and healthy at first glance but could have a health condition or other qualifying criteria. "We don't know," she said. She advises that posters follow what she calls the three core values of manners: respect, honesty and consideration.
And the same goes for people reacting to the posts.
George Francois, 35, a center director at Children's National Hospital in Washington, D.C., chronicled his COVID vaccination on Facebook. Looking at the overall death and infection rates in the African American community, he considered his post a public service. "I could inspire others to get it without having to talk to them directly," he said.
It's a sentiment shared by J. Shawn Durham, 44, an actor in Washington, D.C., and an unintentional "vaccine vulture." He got a call from a friend of a friend to get vaccinated after a scheduled patient missed their appointment — leaving a critical dose that otherwise might have gone to waste. "I am healthy. I am Black. I am scholastic, so I know about our history and the Tuskegee experiments," he said. And, given that history, Durham posted his selfies to "lead by example," he added. "The white and the wealthy are getting vaccinated. I want Black people to want to get vaccinated too."
Francois didn't receive any backlash from his post and didn't think it was a big deal. "A lot of people post their HIV and COVID test results," he said.
Bottom line: It's common among younger adults to publicly share things some older adults may consider to be far too personal.
"It's kind of tacky sometimes, I think, but there's a lot of misinformation out there," said Emilio Delgado, 31, who was born in Puerto Rico and now lives in D.C. He posted in part to foster confidence in the vaccine — to let his connections "see that someone they knew has taken it and didn't grow a third eyeball," he said of his hesitant followers. For that reason, he added, it was worth it.
Delgado, a local actor and patient instructor at the George Washington University School of Medicine and Health Sciences, had access to the vaccine because in this role of "standardized patient" he is often called in to role-play ultrasounds with fourth-year medical students. He makes the bulk of his income through such patient instruction and is frequently at the hospital — a place generally considered high-risk — so he'd rather be vaccinated.
For Signe Hawley, 34, a researcher and volunteer firefighter in the foothills of northwestern Boulder, Colorado, getting the vaccine — and posting about it — was an emotional experience.
Earlier in the pandemic, she made the difficult decision to pull back from her volunteer duties to protect her wife and 2-year-old daughter. But because she had been a first responder in her community, she became eligible for the vaccine sooner than expected. "I wouldn't cut the line," said Hawley. "But when given the opportunity, I wouldn't pass it up either."
For Hawley, the hardest side effect she faced after getting the vaccine was the depth of grief and sadness that surfaced surrounding the loss of her father, along with thoughts of all of the other lives lost "in the mismanagement of this," she said.
Her father, Joe Hawley Sr., 67, died in early April from complications of COVID-19 at Norwalk Hospital in southwestern Connecticut. His family was not allowed into the intensive care unit at any time during his bout with COVID. And her interest in volunteerism and service is something she inherited from her father, a "humanitarian at heart," who was involved and committed to the New England community where he lived.
"To be vaccinated for something that my father died from is so surreal," she said, her voice breaking. Sharing her story and the vaccine photo was a way to honor her father. "This is one step to lessening the impact of death and severe health complications with COVID, but it's not the end of it," she said.
Ultimately, she said, the more people vaccinated the better off we all are.
"We're all posting this hoping to get buy-in," said national etiquette expert Diane Gottsman, an author and founder of the Protocol School of Texas, a company specializing in corporate etiquette training based in San Antonio. Know your audience, she advised. And another important reminder: Follow Federal Trade Commission guidelines, which advise against posting vaccination cards containing identifying information that could expose you to identity theft.
Opening another front in the nation's response to the pandemic, medical centers and other health organizations have begun sending doctors and nurses to apartment buildings and private homes to vaccinate homebound seniors.
Boston Medical Center, which runs the oldest in-home medical service in the country, started doing this Feb. 1. Wake Forest Baptist Health, a North Carolina health system, followed a week later.
In Miami Beach, Florida, fire department paramedics are delivering vaccines to frail seniors in their own homes. In East St. Louis, Illinois, a visiting nurse service is offering at-home vaccines to low-income, sick older adults who receive food from Meals on Wheels.
In central and northern Pennsylvania, Geisinger Health, a large health system, has identified 500 older homebound adults and is bringing vaccines to them. Nationally, the Department of Veterans Affairs has provided more than 11,000 vaccines to veterans who receive primary medical care at home.
These efforts and others like them recognize a compelling need: Between 2 million and 4.4 million older adults are homebound. Most are in their 80s and have multiple medical conditions, such as heart failure, cancer, and chronic lung disease, and many are cognitively impaired. They cannot leave their homes or can do so only with considerable difficulty.
By virtue of their age and medical status, these seniors are at extremely high risk of becoming seriously ill and dying if they get COVID-19. Yet, unlike similarly frail nursing home patients, they haven't been recognized as a priority group for vaccines, and the Centers for Disease Control and Prevention only recently offered guidance on serving them.
"This is a hidden group that's going to be overlooked if we don't step up efforts to reach them," said Dr. Steven Landers, president and CEO of Visiting Nurse Association Health Group, which provides home health and hospice care to over 10,000 people in New Jersey, northeastern Ohio and southeastern Florida. His organization plans to launch a pilot home vaccination program for frail patients this week.
Jane Gerechoff, 91, of Ocean Township, New Jersey, is waiting for the group to vaccinate her. She had a stroke more than a year ago and has difficulty breathing because of a serious lung disease. "I can't walk; I'm in a wheelchair. There's no way in the world I could get the vaccine if they didn't come out to me," she said in a phone interview.
Although Gerechoff doesn't go out, she lives with an adult son who interacts with people outside the house and she receives help from physical and occupational therapists at home. Any one of them could bring in the virus.
Reaching homebound seniors presents many challenges. At the top of the list: Home care agencies and hospice organizations don't have access to COVID vaccines either for their staff or patients.
"There is no distribution of vaccines to our members, and there has been no planning surrounding meeting the needs of the people we serve," said William Dombi, president of the National Association for Home Care & Hospice.
Organizations that administer vaccines also complain they're not being paid enough by Medicare to cover their costs — primarily staff time and effort. (The shots are free because the federal government is paying for them.) Making a vaccine house call requires about an hour on average, including travel, time interacting with patients and post-vaccination monitoring of people for potential side effects, according to program leaders.
Medicare reimbursement for the first shot is $16.94; for a second shot, it's $28.39, according to Shawna Ramey, a consultant who presented the data at a recent American Academy of Home Care Medicine webinar. "The actual cost of these visits is closer to $150 or $160," Dombi said.
Then, there are issues with cold storage and transportation for the Pfizer-BioNTech and Moderna vaccines. Both vaccines are fragile after being thawed and need to be handled carefully, according to the new CDC guidance on vaccinating homebound adults.. Once vaccine vials are opened, shots need to be delivered within six hours, according to instructions from Pfizer and Moderna.
Those requirements have proved too burdensome for Prospero Health, which serves 9,000 seriously ill patients in their homes in 20 states, including nearly 2,000 homebound patients. Fewer than 10% have been vaccinated, said Dr. Dave Moen, Prospero's medical group president.
Things will become easier if vaccines from Johnson & Johnson and AstraZeneca receive approval, as expected, he suggested. Both of those vaccine candidates are more stable than the Pfizer and Moderna vaccines and would be easier to administer in the home, Moen said.
Palmer Kloster, 84, of Bradley, Illinois, receives care from Prospero under a contract with his Medicare Advantage insurer, UnitedHealthcare. He's a largely immobile polio survivor who has undergone open-heart surgery and receives care from paid helpers for four hours a day.
"I really need someone to come here and give me a shot," he told me in a phone conversation. "I don't want that disease [COVID-19]. At my age, it would be very detrimental."
In Boston, Mary Gareffa, 84, is grateful that a physician she knows and trusts, Dr. Won Lee, came to her house in early February to vaccinate her. "I haven't been out of the house in about eight years, except by ambulance," said Gareffa, who has stomach cancer, weighs 73 pounds and broke her hip this summer after a bad fall.
It's essential to reach out to patients like Gareffa, said Lee, a geriatrician who works with the Boston Medical Center's home-based program. "It's worth providing quality of life and reducing suffering, and COVID-19 causes nothing but suffering," she said. The Boston program has vaccinated 84 people as of Feb. 12.
The vaccines come from the medical center's supply. Before going out, staff members call patients and address any concerns they might have about getting the shots. Most are African American and many families want to know whether the vaccine will make their frail parents or grandparents sick. "They need to hear that it's safe to get a shot from someone who knows their medical issues," Lee said.
Wake Forest's house call program is sending out a doctor, nurse or physician assistant paired with a pharmacy resident to deliver vaccines. About 200 people are served through the program, most of them in their late 70s or early 80s with five or more medical conditions, said Dr. Mia Yang, the program's director.
Wake Forest's goal is to provide vaccine house calls to up to 40 patients a week and include family caregivers if there's adequate supply, Yang said.
Robert Pursel, 69, who has severe osteoporosis and fluid retention in his feet and legs, and his wife Gail, 72, who has serious back problems, both received Pfizer vaccines in late January from Geisinger at their home in Millville, Pennsylvania. At first, Robert said he was skeptical, but now he's glad he said yes. If a Geisinger nurse hadn't come to them, he wouldn't have been able to get out on his own.
Because of his swelling, "I can't get my shoes on," Robert said, and "I'd have to walk barefoot through the snow and ice out there."
Officials at the University of Michigan Medical School suggested it may be the first proven case of COVID in the U.S. in which the virus was transmitted via an organ transplant.
This article was published on Sunday, February 21, 2021 in Kaiser Health News.
By JoNel Aleccia Doctors say a woman in Michigan contracted COVID-19 and died last fall two months after receiving a tainted double-lung transplant from a donor who turned out to harbor the virus that causes the disease — despite showing no signs of illness and initially testing negative.
Officials at the University of Michigan Medical School suggested it may be the first proven case of COVID in the U.S. in which the virus was transmitted via an organ transplant. A surgeon who handled the donor lungs was also infected with the virus and fell ill but later recovered.
The incident appears to be isolated — the only confirmed case among nearly 40,000 transplants in 2020. But it has led to calls for more thorough testing of lung transplant donors, with samples taken from deep within the donor lungs as well as the nose and throat, said Dr. Daniel Kaul, director of Michigan Medicine's transplant infectious disease service.
"We would absolutely not have used the lungs if we'd had a positive COVID test," said Kaul, who co-authored a report about the case in the American Journal of Transplantation.
The virus was transmitted when lungs from a woman from the Upper Midwest, who died after suffering a severe brain injury in a car accident, were transplanted into a woman with chronic obstructive lung disease at University Hospital in Ann Arbor. The nose and throat samples routinely collected from both organ donors and recipients tested negative for SARS-CoV-2, the virus that causes COVID.
"All the screening that we normally do and are able to do, we did," Kaul said.
Three days after the operation, however, the recipient spiked a fever; her blood pressure fell and her breathing became labored. Imaging showed signs of lung infection.
As her condition worsened, the patient developed septic shock and heart function problems. Doctors decided to test for SARS-CoV-2, Kaul said. Samples from her new lungs came back positive.
Suspicious about the origin of the infection, doctors returned to samples from the transplant donor. A molecular test of a swab from the donor's nose and throat, taken 48 hours after her lungs were procured, had been negative for SARS-Cov-2. The donor's family told doctors she had no history of recent travel or COVID symptoms and no known exposure to anyone with the disease.
But doctors had kept a sample of fluid washed from deep within the donor lungs. When they tested that fluid, it was positive for the virus. Four days after the transplant, the surgeon who handled the donor lungs and performed the surgery tested positive, too. Genetic screening revealed that the transplant recipient and the surgeon had been infected by the donor. Ten other members of the transplant team tested negative for the virus.
The transplant recipient deteriorated rapidly, developing multisystem organ failure. Doctors tried known treatments for COVID, including remdesivir, a newly approved drug, and convalescent blood plasma from people previously infected with the disease. Eventually, she was placed on the last-resort option of ECMO, or extracorporeal membrane oxygenation, to no avail. Life support was withdrawn, and she died 61 days after the transplant.
Kaul called the incident "a tragic case."
While the Michigan case marks the first confirmed incident in the U.S. of transmission through a transplant, others have been suspected. A recent Centers for Disease Control and Prevention report reviewed eight possible cases of what's known as donor-derived infection that occurred last spring, but concluded the most likely source of transmission of the COVID virus in those cases was in a community or healthcare setting.
Before this incident, it was not clear whether the COVID virus could be transmitted through solid organ transplants, though it's well documented with other respiratory viruses. Donor transmission of H1N1 2009 pandemic influenza has been detected almost exclusively in lung transplant recipients, Kaul noted.
While it's not surprising that SARS-CoV-2 can be transmitted through infected lungs, it remains uncertain whether other organs affected by COVID — hearts, livers and kidneys, for instance — can transmit the virus, too.
"It seems for non-lung donors that it may be very difficult to transmit COVID, even if the donor has COVID," Kaul said.
Organ donors have been tested routinely for SARS-CoV-2 during the pandemic, though it's not required by the Organ Procurement and Transplantation Network, or OPTN, which oversees transplants in the U.S. But the Michigan case underscores the need for more extensive sampling before transplant, especially in areas with high rates of COVID transmission, Kaul said.
When it comes to lungs, that means making sure to test samples from the donor's lower respiratory tract, as well as from the nose and throat. Obtaining and testing such samples from donors can be difficult to carry out in a timely fashion. There's also the risk of introducing infection into the donated lungs, Kaul said.
Because no organs other than lungs were used, the Michigan case doesn't provide insight into testing protocols for other organs.
Overall, viral transmissions from organ donors to recipients remain rare, occurring in fewer than 1% of transplant recipients, research shows. The medical risks facing ailing patients who reject a donor organ are generally far higher, said Dr. David Klassen, chief medical officer with the United Network for Organ Sharing, the federal contractor that runs the OPTN.
"The risks of turning down transplants are catastrophic," he said. "I don't think patients should be afraid of the transplant process."